English - Health Net

Small Business Group
Health Net Life Insurance Company
Plan Overview
Gold 80 PPO (BGB)
Benefit description
Unlimited lifetime maximum.
Insured person(s) responsibility
In-network1,2
Out-of-network1,3
$0 single / $0 family
$0 single / $0 family
$6,250 single / $12,500 family
$12,500 single / $25,000
family
Office visit
$30
50%
Specialist consultation
$50
50%
Preventive care services6
$0
Not covered
X-ray / Laboratory procedures
$50 / $30
50%
Rehabilitation and habilitation therapy
$30
Not covered
Inpatient hospital facility services (includes maternity)
20%
50%
Outpatient surgery (hospital or outpatient surgery center charges
only)
20%
50%
Skilled nursing facility
20%
50%
Emergency room (copayment waived if admitted)
$250
$250
Urgent care
$60
50%
Ambulance services (ground and air)
$250
$250
Mental health / Chemical dependency rehabilitation (inpatient)
20%
Mental health / Chemical dependency rehabilitation (outpatient
office visit)
$30
50%
50%
Home health care services (100 visits/year, in- and out-of-
20%
50%
Durable medical equipment
20%
Not covered
Acupuncture (medically necessary)
$30
Not covered
Chiropractic services
Not covered
Not covered
Plan maximums
Calendar year deductible4
Out-of-pocket maximum
5
Professional services
Hospital services
Emergency services
Behavioral services
network combined)
Other services
Prescription drug coverage
Brand-name calendar year deductible (per insured)
$0 single / $0 family
Not covered
Prescription drugs (up to a 30-day supply)7
$15 / $50 / $70
Not covered
Specialty drugs (including most self-injectables)8
20%
Not covered
$0
$0
Routine eye exam
0%
Not covered
Glasses
1 pair per year
Not covered
Pediatric dental
9
Diagnostic and preventive services
Pediatric vision
10
(continued)
This is a summary of benefits. It does not include all services, limitations or exclusions. Please refer to the Certificate of Insurance (COI) for terms and conditions of coverage.
1
Certain services require prior certification from Health Net. Without prior certification, an additional $250 is applied. Refer to the COI for details.
2
Insured pays the negotiated rate, which is the rate participating or preferred providers have agreed to accept for providing a covered service.
3
Please refer to the COI for out-of-network reimbursement methodology.
4
Any amount applied toward the calendar year deductible (if applicable) for covered services and supplies received from an in-network provider
will not apply toward the calendar year deductible for out-of-network providers. In addition, any amount applied toward the calendar
year deductible for covered services and supplies received from an out-of-network provider will not apply toward the calendar year
deductible for in-network providers.
5
Copayments or coinsurance paid for in-network services will not apply toward the out-of-pocket maximum for out-of-network providers and
coinsurance paid for out-of-network services will not apply toward the out-of-pocket maximum for preferred providers.
6
Covered services based on the United States Preventive Services Task Force (USPSTF) grade A and B recommendations; recommendations
of the Advisory Committee on Immunization Practices (ACIP) that have been adopted by the Director of the Centers for Disease Control and
Prevention (CDC); women’s preventive care and screenings provided for in comprehensive guidelines supported by the Health Resources and
Services Administration (HRSA); and comprehensive guidelines supported by HRSA for infants, children and adolescents. For more information
on generally recommended preventive services, go to www.healthcare.gov. The applicable cost-sharing for preventive care will apply to these
services.
7
The three prescription drug tiers are Tier 1: Generic formulary; Tier 2: Brand formulary; Tier 3: Brand non-formulary.
The Essential Rx Drug List is a list of prescription drugs that are covered by this plan. Some drugs require prior authorization from Health Net.
For a copy of the Essential Rx Drug List, go to Health Net’s website. Refer to the COI for complete information on prescription drugs. Plans will
cover most female prescription contraceptives at $0 cost-share. Coverage on some drugs may not follow the generic and brand tier system.
Please refer to your COI and Health Net’s Essential Rx Drug List for coverage, cost-share and tier information. The COI is a legal, binding
document. If the information in this brochure differs from the information in the COI, the COI controls.
Prescription drugs filled through mail order (up to a 90-day supply) require twice the level of copayment. For details regarding a specific drug,
go to www.healthnet.com.
8
Specialty drugs include high cost medications used to treat complex medical conditions, including covered self-injectable drugs other than
insulin. Specialty drugs require prior authorization and must be obtained from a contracted specialty pharmacy vendor.
9
Pediatric dental PPO plans are underwritten by Health Net Life Insurance Company and administered by Dental Benefit Administrative Services
(DBP). DBP is not affiliated with Health Net. See the plan’s Certificate of Insurance for details.
10
Health Net contracts with EyeMed Vision Care, LLC, a vision services provider panel, to administer the pediatric vision services benefits.
CA112829 (1/15) Health Net PPO insurance plans are underwritten by Health Net Life Insurance Company. Health Net Life Insurance Company is a
subsidiary of Health Net, Inc. Health Net is a registered service mark of Health Net, Inc. All other identified trademarks/service marks remain the
property of their respective companies. All rights reserved.